Healing Children: A Surgeon's Stories from the Frontiers of Pediatric Medicine

Healing Children: A Surgeon's Stories from the Frontiers of Pediatric Medicine

by Kurt Newman M.D.


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Product Details

ISBN-13: 9780143110033
Publisher: Penguin Publishing Group
Publication date: 07/17/2018
Pages: 272
Sales rank: 571,142
Product dimensions: 5.50(w) x 8.30(h) x 0.80(d)

About the Author

Kurt Newman, MD, is president and CEO of Children’s National Medical Center in Washington, D.C., widely recognized as one of the nation’s best pediatric hospitals. Dr. Newman has been a surgeon at Children’s National for over thirty years and is a professor of surgery and pediatrics at George Washington University School of Medicine & Health Sciences. He helped create the Sheikh Zayed Institute for Pediatric Surgical Innovation, dedicated to making children’s surgery pain free and less invasive. A strong advocate for the expansion of mental health treatment access for kids, he is actively involved in improving pediatric health nationally through his work on the boards of the Children’s Hospital Association and Safe Kids Worldwide. He and his wife Alison are the parents of two college age sons and live in Bethesda, Maryland.

Read an Excerpt

The Walk Across the Bridge

Entering Ella's room that morning, I had expected to find her resting peacefully with a nasogastric tube sucking bile from her stomach. What I had not expected was to find her parents and grandfather seated in a semicircle around her with their own tubes sticking out of their noses and taped to their foreheads.

I was a third-year surgical resident at Brigham and Women's Hospital, making rounds with the senior resident-technically my boss that day-on my first rotation in pediatric surgery at Boston Children's Hospital. Both the Brigham and Boston Children's were teaching hospitals affiliated with Harvard Medical School-many of their doctors taught at Harvard, and Harvard Med School students went there for training and to do their residency. Crossing the bridge between the two hospitals, I had felt the senior resident's mood shift from gruff to decidedly grumpy. Now, as we stood in Ella's room trying to make sense of the scene, I felt he was about to erupt.

He was not the first colleague to show frustration in a pediatric environment. After two years of residency at Brigham and Women's, I had grown accustomed to the regular complaints of my peers as they crossed the bridge to Boston Children's, one of the first and best pediatric specialty centers in the nation. I suppose at some level it was to be expected: they were mimicking an attitude common among the famous doctors who were training us. Most of my fellow residents were aspiring brain surgeons, cancer researchers, orthopedists, and heart surgeons. They had little time or energy for anxious parents, let alone for the quirks and tantrums of children.

The previous day the senior resident had brusquely informed Ella's parents she would need a nasogastric tube, which we would have to insert through her nose down into her stomach. Her intestine, which we had untwisted in a relatively common but quite invasive surgical procedure, was still not functioning properly, and we needed to relieve it of all stress to give it a chance to heal. Ella's parents had been patiently waiting for weeks to see some progress, and the news of the tube had visibly crushed them. The prolonged hospital stay was taking a toll on their four-year-old daughter, and they worried the tube would further damage her spirits.

The senior resident didn't seem to register their concerns. He silently examined Ella one last time, then wrote out the order for the tube to be inserted.

I wanted to reassure them somehow but couldn't think of what to say or do that wouldn't seem insubordinate.

Ella's parents moved in closer and spoke more emphatically. "She is not ready for this," her father said, his voice not so much stern as weary, almost pleading. "She's been through too much. We have to be able to explain-in her own language-why she needs this."

My colleague looked up and mumbled, "I'm sorry," and then we were off, leaving them with a look of disbelief.

So the following morning when we entered the room, I was struck by the majesty and outrageousness of their gesture.

"We told you we would do whatever it took to make this easier for her," Ella's father said matter-of-factly. Her mother stood up and moved closer. I will never forget the willfulness-the sheer, animallike protectiveness-that she exuded.

The senior resident blushed and didn't even examine the girl before saying, "This is against hospital policy."

I had to do all I could to keep from wincing.

Ella's mother saw that her daughter was registering the tension in our voices and motioned for us to step into the hallway, but the chief resident would not budge. "You are going to have to remove the tubes immediately or we will ask you to leave the hospital," he said.

The grandfather folded his newspaper and frowned. He looked at his granddaughter, then shook his head and closed his eyes.

"Immediately," he repeated, and out he went, before they could respond.

I trailed after him despondently, angry at myself for doing nothing to intervene. I knew he would follow through on his threat, and I could tell the parents understood this. But if it helped the girl, was it really such a problem?

Over the course of my first pediatric surgical rotation, the trips across the bridge had had the opposite effect on me as on most of my colleagues. I loved working at Children's. It felt a bit like going home. I was raised in North Carolina, earned my undergrad degree at the University of North Carolina, and went to Duke medical school, and I was still recovering from a culture shock that had less to do with the infamous rigors of residency at Brigham and Women's than with the gruffness and wear-it-on-your-scrubs ambition of life among hard-chargers up north.

The care and results at the Brigham were excellent, of course, but the coolness and professionalism there, the dispassionate approach to patient interaction, left me wanting. In three short months I had grown to cherish the heightened authenticity I felt every day at Boston Children's. In my first year as a resident, I had made the trip across the bridge a few times during rotations in plastic surgery and neurosurgery, specialties in which there were no separate pediatric departments, but it wasn't until now, in my third year, that I was doing a full rotation in pediatric surgery.

In the end, Ella's parents removed the tubes from their foreheads, and their daughter's intestines began functioning properly soon thereafter. Her digestive system had been given the respite it needed to recover completely. My boss, having done the right thing in the wrong way, departed a year later for a very successful career in adult surgery, and I was left with nagging questions about the system and my future. Why couldn't hospital policies be adjusted to consider the emotional needs of children and their families? Young parents are so desperate to see their children heal. Shouldn't we adjust our ways to address their needs, too? I began to see the bridge connecting the Brigham and Boston Children's as a passage to a different form of medicine, one that accounted not just for the unique psychology and biology of children but also for the concerns of their families.

A few months later I was back on adult rounds in a general male ward at the Brigham that was typically made up of uninsured patients. One night one of my patients, a man we had nicknamed Mr. Pibb, was feeling uncomfortable. HeÕd had stomach surgery a week before, and the surgeons had placed a nasogastric tube in him, just as they had done with Ella. They wanted his stomach to rest and heal; draining it was key.

The senior resident had directed me to make sure the tube stayed in place all night. Mr. Pibb was notoriously feisty and craved soda pop-hence his nickname, which rhymed with his real name. The painkillers were making him restless, and he was a prime candidate to thrash about and rip his tube out.

The first time the nurse paged me, about midnight, I knew immediately what had happened-the tube had come out. I rushed upstairs and tried to calm Mr. Pibb. Then I gave him all the little extras that I understood to be the hallmarks of a good nasogastric tube insertion. I numbed his nose a little bit to make the placement more comfortable, put the tube on ice to stiffen it a bit so it would be easier to place, and calmly asked him to cooperate with his swallowing as I ran the tube down his throat. Then I taped it in place about as gently as I had ever seen the kindest nurse tape a patient.

An hour and a half later, while I was on my cot catching my first shut-eye of the night, the nurse paged me again. I was by this point, as my mother used to say when I did something wrong, "clearly perturbed." I called upstairs, and the nurse told me that Mr. Pibb had kept thrashing and had pulled the tube out again.

This time I didn't numb his nose or call for ice. I taped the hell out of the tube. I even ordered that he be placed in restraints. Exhaustion and frustration had gotten the better of me, but at least I was certain that he would not be able to dislodge the tube again.

But he did. I had just lain down again when the call came in. A medical student named Robert Sackstein was resting on the cot across the room from me.

"Okay, your turn, Robert," I recall saying. "Nothing like learning on the job." I craved sleep, and having Robert give it a try would buy me a few winks. "But you've got to get them to restrain him completely this time."

The procedure normally takes half an hour with hard cases like Mr. Pibb, so I closed my eyes as Robert got up, and I drifted off before he even closed the door.

But Robert was back ten minutes later. I sat up and asked him what happened.

"What do you mean?" he asked with surprise.

"What happened up there-why are you back so quickly?"

"I put the tube back in and ordered that he be fully restrained," he said.

"That quickly?"

"Well, yes," he said.

"He didn't fight it? He didn't give you a hard time?"

"Well, no," Robert said, obviously trying to get me to shut up so he could get some sleep himself. He turned over, and I suspected he was smiling in the darkness.

"Mr. Pibb did say something to me when I got there," he offered.

"What was that?"

"He said, 'Son, I don't care what you're going to do-just don't call that bald bastard back in here!'"

And with that, Robert broke out laughing. I was, at thirty, already going bald, professional anxiety no doubt expediting genetic destiny. I chuckled and winced not so much at being made fun of as at being found out.

The glaring difference in my experiences of the same procedure on either side of the bridge-and repeated scenarios like it-were starting to make me think that I should go into pediatric medicine. But this was not a field that the best and brightest in Boston's surgical training grounds were encouraged to pursue. Curing cancer and finding solutions for heart disease were the worthy callings for Harvard's most ambitious surgery residents. Pediatric surgery was barely on the radar screen of ambition. I was beginning to feel like a literature student stuck in an engineering class.

Chapter 2:

Learning Empathy

During my first year of residency, a famous doctor by the name of Joe Murray was the head of both adult and pediatric plastic surgery. Plastic surgery was one of the few fields that didn't have distinct department heads at Boston Children's and the Brigham. I quickly realized that being assigned to learn from Dr. Murray for two months meant pushing not only my brain beyond its normal capacity but my body, too. I'd hike up and down the "Pike" all day, marveling at Dr. Murray's talents and his stamina. The layout of the place did not make it easy for him to manage his cases.

The Pike was the nickname for the interminable passage that connected all the wards at Brigham and Women's. It began at the emergency room and ended with the bridge to Boston Children's Hospital. On trauma rotations, when you were on call at night, you could be at one end of the Pike stitching a guy who'd been hit in the face with a bottle and then have to race the length of the Pike and across the bridge to treat a child suffering from a dog bite. To fast-walk the length of the Pike was decent preparation for the Boston Marathon, particularly when you had to do it dozens of times a day, as I did when I was following Dr. Murray. He'd resected a small birthmark at Boston Children's, then rush off to do a facial fracture repair at Brigham and Women's. Back then the Pike was worthy of its namesake (the Mass Pike): gritty, cold, and long.

One of the first patients I saw Dr. Murray operate on was a boy who had been badly burned all over his body. Dr. Murray had already performed a series of skin grafts, and the child was progressing marvelously. Like many of his peers, Dr. Murray had gotten hooked on plastic surgery as a military surgeon during World War II. With so many wounded and burned soldiers in need of skin grafts, he had sought to understand the immunology of transplantation. Why was some skin rejected, and what could be done to prevent it? He also became an expert at transplant surgery and was the leader of the surgical team at the Brigham that successfully transplanted the first human kidney in 1954. Decades later, deep into his next passion, plastic surgery, he won the Nobel Prize in Physiology or Medicine his transplant work.

Dr. Murray was reconfiguring this boy's skin and reducing much of his scarring. He was slowly transforming the person he would become, and the boy seemed to know it. Watching them interact lifted my spirits every morning.

After checking in on the boy, we would hustle across the bridge and cruise down the Pike toward the adult plastic surgery ward. Among the first patients I assisted Dr. Murray with at the gloomier end of the Pike was one of the grouchiest, most disheartening patients I have ever encountered. He certainly had reason to be disgruntled. He was in his late fifties and was suffering from a pervasive head, mouth, and neck cancer. The cancer had so eaten into his face and head that Dr. Murray had been forced to do an incredibly complicated restructuring of the man's jaw and cheeks. This was not cosmetic surgery; it was essential for him to maintain some sort of functioning head and neck. In a series of operations, Dr. Murray had replaced the tissue that had been removed with flaps of soft tissue taken from the man's neck, carefully rotating them into place. The work was art and engineering all in one.

Throughout the nearly ten hours of surgery, I stood transfixed as Dr. Murray connected muscle and tissue and flaps. My job was to monitor the patient's blood supply and vitals-such a long surgery could quickly head south-but at times I caught myself losing track as I marveled at his dexterity. But despite my admiration, I questioned his involvement in the case. I was angry at the patient, and this was becoming a troublesome pattern. He had smoked multiple packs of cigarettes a day and had, I believed, inflicted this awful situation on himself. And still he thought he had a right to curse us and accuse us and generally act disrespectfully to the nurses, who were trying to make his life as tolerable as possible.

Table of Contents

Author's Note xi

Acknowledgments xiii

Introduction 1

Part I Discovering Children

1 The Walk Across the Bridge 11

2 Learning Empathy 17

3 Born to Heal 23

4 Making Mistakes 27

5 Finding a Mentor 32

6 The Head Coach and His Team 36

7 Never Trust the Notes 42

8 If You Can Teach 46

9 You Never Can Tell How Far a Frog Can Jump 52

10 How to Hold a Baby 60

11 "There Are No Conflicts of Interest Here" 67

Part II Vital Lessons

12 Old School 81

13 Maternal Instinct 88

14 Trauma 96

15 That Phantom Pain 108

16 The Patient in the Data 115

17 The Mayor 122

18 A Man with a Plan 130

Part III New Frontiers

19 Thinking Bigger 151

20 Navigating the Hospital 164

21 Mental Health 171

22 A Child's Life 179

23 What You Don't Know 185

24 Brains 194

25 Bones 202

26 The Science of Pain 207

27 Peering into the Developing Brain 216

28 Cancer 224

Epilogue: The Best Man at His Own Wedding 235

Eight Ways to Get the Best Medical Care for Your Kids 243

Index 247

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